esmo preceptorship · 2020. 1. 29. · 1/3 of patients with normal lymph node morphology have nodal...

ESMO PRECEPTORSHIPON BREAST CANCER

MD Associate professor Kristina Lång, Lund University

Lisbon, 11-12 October 2019

Breast imaging

DISCLOSURE OF INTEREST

Speaker fees from Siemens Healthineers

Symptoms Screening finding

Diagnosis

Staging

Preoperative assessment

Postoperative assessment and

surveillance

3Kristina Lång, ESMO 2019


Diagnosis

Staging


Postoperative assessment and

surveillance

Symptoms of breast cancer In the screening age group: >60% of

the cancers are detected in screening

1/2 1/2



Diagnosis

Other imaging techniques: TomosynthesisMagnetic resonance imaging (MRI)Contrast enhanced mammography

Elastography

Breast-CT…

MammographyUltrasoundBiopsy

+ physical examination = Triple assessment


Röntgenskuggbild

• One of the most common x-ray examination

• Measures the attenuation differences of tissues with different densities (radiolucent/radiodense = non dense/dense tissue)

• Tumour = high cellular density

Diagnosis Mammography


Kenneth Libbrecht, Reports on Progress in Physics (2005)

Breasts are a heterogeneous organ

7

Diagnosis

Kristina Lång, ESMO 2019

The sensitivity of mammography is affected by:

• Exam technique – compression, positioning, image quality

• Tumour size and growth pattern (inv. lobular cancer)

• Experience of the radiologist (5000/year)

• Breast density (fatty vs fibroglandular and stromal tissue)

SensitivityRisk

• Increased risk of breast cancer in extremely dense breasts vs fatty breasts (x5)

Boyd NF et al N Eng J Med 2007

• Reduced sensitivity in dense breasts due to masking effect: – Non-dense breasts >70% sensitivity

– Dense breasts <50% sensitivity

8

Diagnosis


• Mediolateral oblique (MLO)

• Craniocaudal (CC)

• Lateral (ML eller LM)

• Additional views:- Magnification- Axilla

Standard views

MLO + CC = screening

MLO + CC + LM = clinical

9

Diagnosis


Breast compression

• Reduces scattered radiation/secondary radiation – lowers the radiation dose

• Reduces image noise

• Separates the structures in the breast – improves visualization

• Breast compression can be painful

• Influences the participation rate in screening (25–46% of those who chooses not to re-attend screening say that compression pain is the reason)

Whelehan et al. The effect of mammography pain on repeat participation in breast cancer screening: A systematic review. The Breast (2013)

10

Diagnosis


One mammogram = 3 months exposure to background radiation

www.iaea.org/Publications/Factsheets

Radiation dose in x-ray imaging

11

Diagnosis


www.iaea.org/Publications/Factsheets

Carcinogenic effect of irradiation is age dependent

• All symptomatic women >30 y.o.

• Women 25–30 y.o. only with a clinical suspicion of malignancy

• <25 y.o. only with a strong suspicion of malignancy

12

Diagnosis

Adapted from Baral et al Cancer 1977


• Soft tissue lesion

• Architectural distortion

• Asymmetry

• Microcalcifications

• Associated findings

Features of cancers

The most common appearance of an invasive cancer = a spiculated mass

13

Diagnosis


IDC FA

• 10–20% have benign features

• Often fast growing trippel negative breast cancers

• Medullar och mucinous cancer

TNBC

SpiculationsIrregular marginHigh densityEccentric localization

Round/ovalCircumbsribedSmooth marginIsodense/low densityHalo

Soft tissue lesion

Signs of malignancy Signs of benignity

14

Diagnosis


Architectural distortion

Multicentric invasive lobular cancer

Distortion of the breast parenchyma without a visible mass

Manisha Bahl et al. AJR (2015)

Can be caused by:

• Invasive cancer (lobular type)

• Benign lesions (radial scar, complex sclerosing adenosis)

• Postoperative distortion

Radial scar

15

Diagnosis


Microcalcifications

• Typical benign calcifications:

- Punctate or coarse

- Diffuse or isolated group

- Bilateral

• Typical malignant calcifications:

- New

- Thin, pleomorphic

- Linear, branching (ductal pattern)

- Isolated group or segmental

- Unilaterale

Benign

Malignant

16

Diagnosis


Associated findings

Lymphadenopathy

Unilateal oedema/skin thickening

Skin retraction

17

Diagnosis


Classification of imaging findings

ACR BI-RADS 5th ed.

Breast Imaging Reporting and Data System (BI-RADS)

18

Diagnosis


High-frequency sound waves are reflected in various degrees on different types of tissues

Ultrasonography

• Included in the standard diagnostic assessment

- Characterize lesions seen on mammography

- Lymph node assessment

• Guidance at interventional procedures

• Single modality for assessment of young women (<30)

Indications:

Lazzaro Spallanzani (1794)

19

Diagnosis


38-y.o. woman with a lump

Multifocal IDC

20

Characterization of mammography findings

Mucinous cancer

Benign cyst

Case courtesy of Dr Mark Holland

Mammography Ultrasound

21

Diagnosis


Irregular shapeIndistinct marginsNon-parallell to the skinHypo- or heteroechogenicThrough transmission shadowNon-compressable

Malignant signs Benign signs

Round or ovalDistinct marginsParallell to the skinHomogen echogenicityThrough transmission enhancementCompressableIDC Cyst

”Taller than wide”

Feature analysis

22

Diagnosis


IDC IDC

Fibroadenoma TNBC

Cancer or not?

23

Diagnosis


Needles

Fine needle aspiration Core needle biopsy Vacuum assisted biopsy

Evacuate cystsLymphnode

Histological diagnosisReceptor status

Sparse microcalcificationsMR-guided biopsy

24

Diagnosis



Diagnosis

Staging

Multidisciplinary conferences

25

Size, multifocalityLymph node assessment

Metastasis screening




Breast MRI

Peters et al. 2008 Radiology

Staging

T1W

T2W

Dynamic

MIP

26

• Affects and measures the nuclear-magnetic resonance of water molecules

• Enables analysis of contrast dynamics (tumours = fast uptake + fast wash-out)

• Not affected by breast density

• High sensitivity (90%), lower specificity (72%)


Bilateral ca?

56-y.o. woman with a family history of breast cancer Palpable lump left breast

Bilateral cancer?

27

Staging


• An MRI of the breast is not routinely recommended, but should be considered in cases of:

Indications

Breast MRI

28

Staging

Cardoso F et al. Annals of Oncology (2019)


• Preoperative MRI is clinical practice in many countries

• Tumour size can be underestimated with mammography and ultrasound, especially invasive lobular carcinoma

• MRI is accurate in estimating tumour extension (multifocality)

• A meta-analysis showed that the risk for recurrent disease was not reduced using preoperative MRI, but the risk of mastectomies increased

• COMICE-trial: RCT evaluating the effect on reoperation rates with and without preoperative MRI. No effect on reoperation rates (19% vs.19%, OR 0.96)

• MONET-trial: RCT of nonpalpable cancers with and without preoperative MRI. No difference in mastectomy frequency. Paradoxal higher rate of women with MRI that underwent reoperation (45% vs. 28%)

Preoperative assessment with MRI

Houssami N et al J Clin Oncol (2014)

Houssami N et al Breast Cancer Res Treat. (2017)

R Mann et al. Eur Radiol (2008)Clauser P, et al. Eur Radiol (2018)

L Turnbull et al. Lancet (2010)

”Breast MRI should not be used routinely for preoperative work-up of patients with nonpalpable breast cancer.”

N.H.G.M. Peters et al. Eur J Cancer (2010)

Invasive lobular cancer can be considered as an acceptable indication to preoperative MRI

EUSOMA guidelines, Eur J Cancer (2010)

29

Staging


Lymph node assessment

• Majority of sentinel lymph nodes are located in the lower part of the axilla (Level 1)

• Morphology och cortical thickness (>4 mm)

• Negative axillary US excludes advanced nodal disease with a NPV of 96%

• 1/3 of patients with normal lymph node morphology have nodal metastases

• Biopsy or cytology (+ clip marking)

Schipper RJ et al., Breast (2013)

Seidman H et al, CA Cancer J Clin (1987)

Britton P, Clin Radiol (2010)

30

Staging


Screening for distans metastasis

• Incidence of metastatic disease in early-stage BC <2%

• Whole body screening (CT) justified:

31

Staging

• PET-CT (FDG) can be considered for inconclusive CT, for high-risk patients, inflammatory BC

• Less sensitive for lobular and low-grade cancers

Cardoso F et al. Annals of Oncology (2019)



Diagnosis

Staging



Postoperative assessment

Localization proceduresAssessment of neoadjuvant therapy

Specimen radiographySurveillance

Multidisciplinary conferences

32

Size, multifocalityLymph node assessment

Metastasis screening




76-y.o. woman with pain in her left breast

after a trauma

5 mm invasive tubular cancer



Postoperative assessment

Non-palpable lesions Margins?


• Tumour size before, during and after treatment (longest diameter)

• Before treatment: radiopaque marker

• MRI is the most accurate method to evaluate treatment response (but depends on baseline appearance)

Assessment of neoadjuvant therapy

Before After



• Follow-up vary

• Yearly mammography +/- US (later routine screening)

• MRI may be indicated for young patients (dense breasts, hereditary risk)

• US can also be considered in the follow-up of lobular invasive carcinomas

Surveillance after treatmentPostoperative assessment


• Assessment of primary tumour: Triple assessment = physical examination + imaging (mammography + US) + biopsy

• MRI has high sensitivity and is a valuable tool in selected cases

• Assessment of regional lymph nodes: Physical examination + US + biopsy/cytology if suspicious

• Assessment of metastatic disease: Imaging only if high tumour burden or indicative symptoms

Breast imaging Summary


Thank you for your attention!

[email protected]

esmo preceptorship · 2020. 1. 29. · 1/3 of patients with normal lymph node morphology have nodal...

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